Endoscopic Lung Volume Reduction by Endobronchial Coils: First Report From Latin America

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Excerpt

To the Editor:
Chronic obstructive pulmonary disease is a chronic respiratory disorder with an adjusted prevalence of 6.9% in Chile according to the PLATINO study.1 Smoking cessation and oxygen therapy can alter mortality. Pulmonary rehabilitation and the use of inhalers have improved quality of life and exercise tolerance.1
Endoscopic lung volume reduction seeks to reduce air entrapment by installing a system (endobronchial valves, coils, and others) that reduces the volume of the target lobe and leaves more space in the chest cavity for the remaining parts of the lung to expand, thereby improving respiratory mechanics and dyspnea.2
We report 2 cases of coils in Chile. A 75-year-old man with a history of coronary heart disease and severe pulmonary emphysema undergoing treatment with long-acting muscarinic antagonist+long-acting β2-adrenergic agonist and pulmonary rehabilitation; chest X-ray with bilateral lung hyperexpansion and right dominance (Fig. 1A); chest CT with homogeneous emphysema and right dominance with incomplete fissures (<75%); forced expiratory volume 1 (FEV1), 0.52 Lt (24.93%); 6-minute walking text (6MWT), 194 meters; residual volume (RV), 6.28 Lt (286.5%); and St. George Questionnaire, 65 points. Eleven coils were installed in right upper lobe without incident.
Ten days later, the patient required hospitalization in the Intensive Care Unit for pneumonia of the treated lobe (Fig. 1B). Initially required noninvasive ventilation, had a good response to antibiotic treatment, and was discharged to the home, 7 days later. At 3 months, the chest X-ray showed retraction of the right upper lobe and an elevated minor fissure (Fig. 1C). The FEV1 improved to 0.70 Lt (33.56%), and the RV decreased to 5.50 Lt (250.9%); St. George questionnaire, 56 points and 6MWT, 268 meters.
Second patient was a 68-year-old woman with severe emphysema undergoing therapy with long-acting muscarinic antagonist+long-acting β2-adrenergic agonist+inhaled corticosteroids and pulmonary rehabilitation; chest X-ray with evidence of lung hyperexpansion; chest CT confirming homogeneous emphysema with incomplete fissures (<75%); St George Questionnaire, 58 points; 6MWT, 165 meters; FEV1, 0.40 Lt (23%); and RV 4.75 Lt (247%). Thirteen coils were installed in left lower lobe (Fig. 2A). She had severe bilateral bronchospasm immediately after the procedure with rapid improvement upon usual treatment; discharged home 4 days later. Consultation with an Urgent Care facility 2 weeks later for moderate hemoptysis and new pulmonary infiltrates around the apical coils (Fig. 2B). She was hospitalized for 3 days but did not require other treatments. Evaluation at 3 months found improved parameters, FEV1 0.68 Lt (39.1%); RV, 4.08 Lt (208%); St. George, 50 points; and 6MWT, 217 meters and radiological improvement at 3 months (Fig. 2C).
Coil installation produces a compression and retraction of parenchyma secondary to its spiral shape. Patients with incomplete fissures and collateral ventilation are considered candidates. The coils can be used for both homogeneous and heterogeneous emphysema. The RESET trial included 23 patients with coils and compared the results with conventional therapy, showing significant differences of 14.19% versus 3.57% in FEV1 in favor of the intervention, a decrease in RV, and increases in the 6MWT and quality of life.2
Slebos et al3 reported meta-analyses of 140 patients, 2536 coils, predictors of good response indicated statistically significant differences for patients with an RV decrease greater than 0.4 Lt. Complications included 37 exacerbations, 27 pneumonias, and 6.4% pneumothorax.
The REVOLENS study was a multicenter randomized study of 50 patients with standard management and 50 patients managed with at least 10 coils in each lung lobe. The primary outcome was an improvement of at least 54 meters on the 6MWT, with a statistically significant difference of 18% between groups, and a difference in quality of life, as indicated by a difference of 5.8 points on the St. George questionnaire.
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